Development, Implementation, and Dissemination of the ...

Sonia A. Duffy, PhD, RN, FAAN

The Ohio State University, College of Nursing and

the VA Ann Arbor Healthcare System

[email protected]

Development, Implementation, and

Dissemination of the Nurse-Administered

Tobacco Tactics Intervention

Review data from my prior studies◦ Head and neck cancer longitudinal study

◦ RCT of the nurse administered combined depression, alcohol,

and smoking intervention

◦ Dissemination of the Tobacco Tactics intervention in the

Department of Veterans Affairs (VA)

◦ Dissemination of the Tobacco Tactics intervention in 5 community

hospitals

◦ RCT of Tobacco Tactics for Operating Engineers

Future directions

Longitudinal study to determine if health behaviors,

comorbidities, and molecular markers are major predictors

of quality of life, recurrence, or survival (N=811).

Multivariate Model Variable Hazard Ratio 95% CI P-Value

Smoking Status (vs. Never Smoked) Current Smoker 2.36 1.28-4.37 .006* Former Smoker 2.02 1.16-3.51 .013* Alcohol Problem 1.32 0.91-1.93 .146 PASE Physical Activity (per 10 pts) 0.98 0.95-1.00 .085 MOS Sleep Scale (per 10 pts) 0.96 0.89-1.04 .350 Low Fruit Intake (none to 1-3 per month)

1.26 0.88-1.81 .208

Low Vegetable Intake (none to 2-4 per week)

0.82 0.59-1.15 .242

Age (in Decades) 1.50 1.25-1.79 <.001* Female Gender 0.74 0.47-1.16 .183 Non-White 1.09 0.68-1.77 .715 Married 0.87 0.63-1.21 .413 High School Education or Less 1.43 1.03-1.99 .032* Cancer Site (vs. Oral Cavity/Sinus) Larynx Cancer Site 0.41 0.24-0.69 <.001* Pharynx Cancer Site 0.61 0.39-0.94 .026* Stage 1.52 1.25-1.85 <.001* ACE-27 Comorbidity Score 1.15 0.96-1.37 .125 Radiation 0.75 0.42-1.32 .318 Chemotherapy 0.96 0.62-1.47 .835 Surgery 0.69 0.49-0.99 .043*

* Significant at P < .05

Multivariate models

Variable Hazard ratio 95% CI p value

Smoking status (vs never)

Continuing smokers 4.45 1.29-15.37 .018*

Quitters at Dx (stayed quit 2 yrs.) 3.18 0.89-11.43 .076

Former smokers 2.38 0.99-5.74 .054

Controlling for: Age,* Sex, Race, Marital Status, Education, Income, CPD, ETOH,

BMI, CA site and stage, Comorbidities, Depression, Radiation, Chenmotherapy,*

and Surgery*

• Head and neck cancer patients who screened

positive for smoking, problematic alcohol use,

or depression were eligible to be randomized

between a nurse-delivered, combined

intervention group and an “enhanced usual

care” group (N=184).

Enhanced Usual Care◦ Patients receive brief counseling from the nurse and are

given referrals to specialty care clinics.

Intensive Nursing Intervention◦ Delivered by a nurse practitioner

◦ Based on Cognitive Behavioral Therapy (CBT)

◦ Regularly scheduled phone calls for 6 months◦ Pharmacologic Component

• Core Chapters

• H&N Cancer

• Emotional impact

• Body image

• Behavioral

therapy

• Relaxation

• Communication

• “Mood Management”

• “Tobacco Tactics”

• “Drinking Decisions”

• Resources/Reference

The nurse practitioner provides medications as needed, including:◦ Antidepressants

◦ Smoking Medications

Nicotine replacement therapy (NRT)

Bupropion (Zyban)

Combination NRT and Bupropion

Varenicline (Chantix)

Disorder Usual Care

% Improved

Intervention

% ImprovedP-value‡

Smoking n = 136

31% (19/62)

47% (35/74)

.0481

Alcohol Problem n = 52

30% (8/27)

32% (8/25)

.8532

Depressive Symptomsn = 126

24% (15/63)

21% (13/63)

.6682

‡ χ2 test of association

89% would recommend the intervention to someone else who was dealing with similar issues (cancer, smoking, drinking, or depression).

“If a person reads and studies the manual, it can’t help but change his or her life.”

“The program did what I was trying to do for 20 yrs.”

“Reinforced the fact that I was not unique in my reactions to cancer, smoking and moods.”

Treatment of these behaviors/disorders in combination may

be more successful and practical than treating these

conditions individually.

A 2009 NIH meeting on the Science of Behavior Change

acknowledged the idea that risk behaviors often occur in

“bundles” and the importance of focusing on clusters that may

have common underlying processes (National Institutes of

Health, 2009).

Problem: Intervention ended when randomized control trial

ended.

So how do we get these services integrated into health care

environments?

*This study was conducted at the University of Michigan, supported

by a grant from GlaxoSmith Kline and at the Ann Arbor VAMC,

supported by VA grant IIR 98-500.

The objective of this project was to implement and

evaluate the effectiveness of an inpatient, nurse-

administered Tobacco Tactics program in three

Veterans Affairs hospitals.

Patients admitted to the Ann Arbor and Detroit VAs received the

Tobacco Tactics intervention, while patients admitted to the

Indianapolis VA received usual care.

Tobacco Tactics toolkits for nurses and patients were developed

and training sessions were implemented.

Formative (process) evaluation (patient and staff interviews and

surveys).

Once nurse trainers were withdrawn, sustainability and

summative evaluation was conducted.

Summative (outcome) evaluation (6-month cessation rates) –

Smokers in all sites were surveyed at baseline and 6 months

(plus mailed a urine cotinine test) after discharge about their

smoking habits.

One contact hour for training

PowerPoint presentation on behavioral and

pharmaceutical interventions

Behavioral and pharmaceutical protocols

Pocket card “Helping Smokers Quit: A Guide for

Clinicians”

Computerized template for

documentation

Assess if patient interested in quitting. If patient not interested, leave brochure at bedside. If patient interested, leave brochure and arrange for patient to

view videotape. After videotape, provide patient with patient manual to read if

able. Using patient manual, assist patient with behavioral

intervention including:◦ Self-assessment◦ Smoker type◦ Smoking costs◦ Handling cravings◦ Relapse prevention◦ Medication options

Along with patient, identify and arrange for cessation medications (see pharmaceutical protocol).

Arrange for follow-up calls.

1. Recommend nicotine replacement (patch, gum, or lozenge) if:

◦ Never used patch, gum, or lozenge before.

◦ Used patch, gum, or lozenge successfully in the past (smoke-free > 3

months).

2. Recommend nicotine replacement (patch AND gum OR lozenge) if:

◦ Smoke greater than 1 pack per day

◦ Failed nicotine replacement therapy in past

3. Recommend Bupropion if:

◦ Failed nicotine replacement monotherapy in the past (smoke-free <3

months).

◦ Patch, gum, or lozenge intolerant (i.e. rash, etc.).

◦ History of depression or currently has depressive symptoms.

4. Recommend combination nicotine replacement (patch, gum, or lozenge)

and Bupropion if:

◦ Failed nicotine replacement and Bupropion monotherapy in the past.

5. Recommend Varenicline if:

◦ Intolerance or treatment failure to nicotine replacement and bupropion.

Brochure

Videotape – Smoking: Getting Ready to Quit

Tobacco Tactics manual

1-800-QUIT-NOW card

Pharmaceuticals (physician sign off on meds;

reminded physicians to give advice to quit)

Volunteer follow-up telephone calls

Approximately 96% (210/219) of inpatient nurses

in the Ann Arbor, MI site and 57% (159/279) in

the Detroit, MI site were trained, with an

additional 282 non-targeted personnel

spontaneously attending.

Nurses’ self-reported administration of cessation

services increased from 57% pre-training to 86%

post-training (p<0.0001).

Ann Arbor (N=387)

Detroit(N=247)

Indianapolis (N=269)

Pre-In=203

Post-In=184

P-ValuePre-I

n=201Post-In=46

P-ValuePre-I

n=132Post-In=137

P-Value

% % % % % %Adjusted self-reported 6-month quit ratea

6.5% 6.1% 0.87 4.0% 12.7% 0.05 26.4% 12.4% <0.001

Adjusted cotinine-verified 6-month quit ratea

5.4% 4.9% 0.82 3.7% 6.2% 0.48 18.0% 11.6% 0.01

aPropensity score includes: age, comorbid diabetes, admitted for heart disease, stroke,

surgery or psychiatric problems, self-rated health and thinking that quitting smoking will

be difficult.

Self-reported 6-month cessation

Cotinine-verified 6-month cessation

Beta (SE) P-value Beta (SE) P-value

Intercept -1.13 (0.53) 0.03 -1.72 (0.64) 0.009

Ann Arbor site (vs. Indianapolis) -1.12 (0.39) 0.004 -0.55 (0.47) 0.24

Detroit site (vs. Indianapolis) -1.03 (0.38) 0.007 -0.79 (0.49) 0.11

Post-intervention time period (vs. pre-intervention)

-2.51 (0.75) 0.001 -1.73 (0.79) 0.03

Ann Arbor site X Post-intervention time period

2.50 (0.88) 0.004 1.71 (0.93) 0.07

Detroit site X Post-intervention time period

3.58 (0.91) <0.001 2.40 (1.06) 0.02

Nurse training has been incorporated into new

nurse employee orientation.

Program continues to thrive on its own in Ann

Arbor, Detroit, and Chicago.

In 2011, the Joint Commission released new

standards which apply to all inpatient smokers

and include tobacco use screening, treatment in

the hospital, treatment at discharge, and follow-up telephone contact 1 month after discharge.

The objective of the study was to test the the nurse-administered Tobacco Tactics intervention versus usual care in 5 Trinity Health community hospitals.

Quasi-experimental design.

Convenience sample of 5 Michigan Trinity Health communityhospitals.

Three hospitals received the nurse-administered Tobacco Tactics intervention and 2 received usual care.

O=Observation

X=Intervention

Population Quit

Rates Pre-

Intervention

Population Quit

Rates Post-

Intervention3 Intervention

HospitalsO1 X1 O2

2 Usual Care Control

HospitalsO1 O2

1 continuing education unit (CEU) for training.

PowerPoint presentation on behavioral and pharmaceutical protocols.

Pocket card “Helping Smokers Quit: A Guide for Clinicians”.

Physician reminder to offer brief advice to quit to patients, which was coupled with medication sign-off.

Computerized template for nurse documentation based on the components of Joint Commission Smoking Cessation standards.

Brochure.

Cessation digital video disc (DVD).

Tobacco Tactics patient manual.

Nurse behavioral counseling and pharmaceuticals.

1-800-QUIT-NOW card.

Follow-up phone calls by trained hospital volunteers.

All inpatients were screened for smoking on the nursing assessment.

Nurses were instructed to give smokers brief advice to stop smoking.

There were no systematic protocols in place for medications, which were only sporadically provided.

Nurse/Personnel Participation Variables n %

Targeted inpatient RN and licensed

practical nurses (LPNs) participated in the

training

1,028/1,352 76%

Non-targeted providers participated in the

training317

Extremely/somewhat satisfied with the

training1,336 90%

VariablePre Intervention=1345

Control=375n (%)

Post Intervention=849Control=296

n (%)

Chi-SquareP value

Smoking cessation is very or extremely important

Intervention 1015 (75.9) 567 (83.6) <0.001

Control 249 (75.0) 145 (54.9) <0.001

Very or extremely confident in ability to provide smoking cessation

Intervention 382 (28.6) 387 (57.1) <0.001

Control 141 (43.1) 80 (30.3) <0.001

Currently provide smoking cessation services

Intervention 1134 (84.9) 635 (92.4) <.001

Control 273 (82.0) 195 (73.0) 0.009

VariablePre Intervention=1345

Control=375n (%)

Post Intervention=849Control=296

n (%)

Chi-SquareP value

Advice

Intervention 940 (83.9) 588 (93.5) <.001

Control 242 (90.3) 161 (83.9) 0.039

Individual counseling

Intervention 267 (23.8) 255 (40.7) <.001

Control 91 (34.1) 53 (27.7) 0.150

Group counseling

Intervention 48 (4.3) 43 (6.9) 0.019

Control 21 (7.9) 24 (12.6) 0.095

Medications

Intervention 845 (75.7) 533 (85.6) <.001

Control 227 (84.7) 157 (81.8) 0.404

Hand-outs

Intervention 1022 (91.1) 593 (94.3) 0.017

Control 200 (74.6) 148 (77.1) 0.545

DVD

Intervention 94 (8.4) 88 (14.0) <.001

Control 16 (5.9) 13 (6.8) 0.709

Phone calls

Intervention 35 (3.2) 43 (6.9) <.001

Control 9 (3.4) 7 (3.7) 0.866

VariablePre Intervention=1345

Control=375n (%)

PostIntervention=849

Control=296n (%)

Chi-SquareP value

Face barriers that make it difficult to provide smoking cessation services

Intervention 1042 (78.9) 431 (64.2) <0.001

Control 199 (59.9) 148 (56.1) 0.340

Barriers indicated:

Lack of confidence

Intervention 198 (14.7) 74 (8.7) <0.001

Control 24 (6.4) 16 (5.4) 0.589

Not enough training

Intervention 435 (32.3) 42 (4.9) <0.001

Control 78 (20.8) 67 (22.6) 0.566

Not enough time

Intervention 665 (49.4) 246 (29.0) <0.001

Control 104 (27.7) 87 (29.4) 0.636

Hesitant to upset patients

Intervention 378 (28.1) 134 (15.8) <0.001

Control 49 (13.1) 53 (17.9) 0.083

Not my job

Intervention 50 (3.7) 8 (0.9) <0.001

Control 15 (4.0) 22 (7.4) 0.053

Note: Only 444 (33%) NicAlert strips were returned; patients told us they were “turned off” by the urinary cotinine strips.

Overall self-reported quit ratesIntervention Sites

N=884Control Sites

N=486

Pre-intervention 6.8% 6.2%

Post-intervention 17.6% 7.4%

P-Value <.001 .741Cotinine-verified quit rate*

Pre-intervention 3.7% 2.5%

Post-intervention 7.1% 3.2%

P-value <.05 .670

Self-reported quit rate by siteMuskegon

MercyN=132

Ann ArborN=349

Grand RapidsN=403

Muskegon

HackleyN=215

LivoniaN=271

Pre-intervention 5.4% 7.2% 6.8% 6.5% 5.9%

Post-intervention 13.2% 14.2% 23.4% 8.3% 6.6%

P-value 0.137 0.038 <0.001 0.617 0.814

• Self-reported 6-month cessation

Cotinine-verified 6-month cessation

Beta (SE) P-value Beta (SE) P-value

Intercept-2.82 (0.34)

<0.0001-3.63 (0.69)

<0.0001

Intervention sites (vs. Control sites)

-0.10 (0.45)

0.820.32

(0.73)0.66

Post-intervention time period (vs. pre-intervention)

0.16 (0.34)

0.650.24

(0.91)0.79

Intervention sites X Post-intervention time period

0.90 (0.43)

0.040.46

(1.00)0.65

At the end of the study, nurses in the control hospitals were also trained.

Nurses in the hospitals continue top implement the intervention.

http://va-tobaccotactics.nursing.umich.edu/

◦ test, testpass

http://bcbsm-operatingengineers.nursing.umich.edu/

◦ Talvarez, testpass

Tobacco Tactics

N=59

1-800-QUIT-NOW

N=68P value

Thirty-day quit rate 27% 8% .004

Six-month quit rate 12% 12% NS

Among smokers at 6 months, Cigarettes smoked/day(Change from Baseline)

-6.6 1.0 .02

>50 manuals sent

<50 manuals sent

• Focus Groups and Interviews with Cancer

Patients (Never, Former, and Current Smokers),

Caregivers, and Staff (N=47) at Six

Comprehensive Cancer Centers (CCCs)

• (Dana Farber, Hopkins, Duke, Emory,

Northwestern, OSU)

Smoking and Cancer Patients

•Need human touch

•Empower them: You can take control and we will

help you.

•Workbook a good idea.

•“I know my nurse” – they can be a big help.

•Relationship with nurse is golden

•Would be great to have healthcare team assist me

to quit

Comments on Tobacco Tactics

• Would be a stranger.

• My husband would never have called a quit

line

• Too much on plate already to call quit line

• Nurse would have to “sell” it.

• Make the 1st call with the nurse

Comments on Referral to NCI Resources